If your pain is not controlled by a painkiller from step one on the analgesic ladder, your nurse or doctor will prescribe a painkiller from step two.
For example, if you’re taking a mild painkiller such as paracetamol but are still getting pain, your doctor should prescribe a weak opioid from step two. This may be a painkiller such as dihydrocodeine, codeine phosphate or tramadol. If the pain still isn’t controlled or it increases, your doctor could then prescribe a strong opioid from step three, such as morphine.
You don’t have to start with painkillers from the mild group – if you have moderate or severe pain when you first see your doctor, you can start by taking painkillers from step two or step three.
Often, non-opioid painkillers are used at the same time as weak or strong opioid painkillers, as they work in different ways.
For example, a strong painkiller such as morphine can be used with a mild painkiller such as paracetamol or ibuprofen.
At each step of the analgesic ladder, other medicines can also be used to control pain. These include bisphosphonates, steroids and drugs for nerve pain. Although they are not painkillers, they can be used for certain types of pain.
There is more information about how non-opioid, weak opioid and strong opioid drugs are given below.